Limitations and problems of classification

Although a great deal of work has been devoted to making the official international classification systems both reliable and valid, it must be acknowledged that they are still imperfect. The descriptive categories are continually being revised; for example, 'panic disorder' and 'post-traumatic stress disorder' were only recently listed as diagnoses, although the clinical phenomena have been recognized for many years.

The boundaries between some of the clinical syndromes are not absolute, as illustrated by the need for terms such as 'schizo-affective disorder' to describe an illness with mixed features of two supposedly discrete categories, 'schizophrenia' and 'affective disorder'. Some patients' symptoms do not fit well with any recognized category, and there is a danger that these may be forced into a residual or 'dustbin' category such as 'depression, not otherwise specified'. In insurance-based health systems, this may make the difference between receiving care or not, as insurers may restrict cover to certain 'hard' diagnostic categories.

Insensitive use of classification can lead to 'labelling' of patients. Classification systems are best used in a flexible and critical way, and clinical effort is often better directed toward relieving the patient's symptoms than excessive debate about the niceties of diagnosis.

Some mental health professionals prefer 'problem-based' to 'disease-based' care. Nurses, in particular, and also other non-medical professions such as social workers, have a tradition of a 'problem-oriented' approach. For example, if a social worker is trying to help a mental health patient find supported accommodation, so that they can leave hospital, the details of diagnosis will be less of a priority, than the patient's coping skills, attitude to illness, lifestyle, and likely cooperation with mental health services. The same applies to cognitive behavioural psychotherapy, where the approach depends upon developing a shared understanding between patient and therapists of what the problems are and how they should be addressed; the details of the precise ICD or DSM diagnosis would be of secondary importance.

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